THE MICHENER INSTITUTE FOR APPLIED HEALTH SCIENCES
2015-2016 SINGLE OPT IN FOR MEDICAL RADIATION SCIENCE STUDENTS
This form will enable you to opt in for health benefits for the school year. Please fill in the corresponding application section below.
Please note that you must be taking at least 3 courses to qualify as a part time student.
STUDENT INFORMATION
PLEASE PRINT CLEARLY
Surname: _________________________________________________________ First Name: ________________________________________________
Student ID#: ____________________________________ DOB: Y/________M/______D/______ Gender: M____F____ Date: ___________________
Home mailing address : __________________________________________________________ City__________________Postal Code _____________
Phone Number: _____________________ Campus: ___________________ Name of Program: _____________________________________________
PLEASE ENROLL ME IN THE FOLLOWING :
MRS
Students
OPT-IN
* To be eligible, you must have current OHIP or equivalent coverage.
OPT IN DEADLINE
September Start – October 1, 2015
I wish to apply for:
(indicate by checkmark)
____ $ 209.58 HEALTH & DENTAL BENEFITS (commencing September)
I wish to apply for The Michener Institute for Applied Health Sciences Student Health Plan Benefits above and agree to be bound by
the benefit plan terms and conditions.
PLEASE MAKE PAYMENT USING A CERTIFIED CHEQUE OR MONEY ORDER TO:
ACL Student Benefits
1 Yonge Street, Suite 1200
Toronto, ON
M5E 1E5
========================================================================================
FAMILY APPLICATION
PLEASE ENROLL THE FOLLOWING MEMBERS OF MY FAMILY:
MRS
Students
FAMILY
OPT-IN
_____________________________________
Surname
_________________________________
First Name
y/_______ m/_____ d/_____ ________________________
DOB
Relationship to Student
_____________________________________
Surname
_________________________________
First Name
y/_______ m/_____ d/_____ ________________________
DOB
Relationship to Student
_____________________________________
Surname
________________________________
First Name
y/_______ m/_____ d/_____
DOB
________________________
Relationship to Student
OPT IN DEADLINE
September Start – October 1, 2015
____ $292.33 Health & Dental Plan Benefits (one dependent)
____ $328.85 Health & Dental Plan Benefits (two or more dependents)
I wish to apply for The Michener Institute for Applied Health Sciences Student Health Plan Benefits for the Dependents registered
above and agree to be bound by the benefit plan terms and conditions.
PLEASE MAKE PAYMENT USING A CERTIFIED CHEQUE OR MONEY ORDER TO:
ACL Student Benefits
1 Yonge Street, Suite 1200
Toronto, ON
M5E 1E5
SIGNATURE OF STUDENT:_____________________________________________DATE_____________________________________